Laparoscopic Right Hemicolectomy

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Essential equipment:
  • One 5mm, two 12mm disposable trocars
  • 5mm fenestrated Johan grasping forceps
  • 5mm Harmonic scalpel or Bipolar shears 
  • Medium (purple) Haem-o-Lock Clips 

Use gravity as much as possible and always use a 300 scope.

Stand on the patients left (standing between the legs doesn’t really help and limits hand movement).  

The camera holder stands to the right of the operating surgeon.  20 degrees of left sided tilt and a small amount of head down tilt.

In obese patients insert the 12mm trocar to the left of the umbilicus.  Place the lower ports as in appendicectomy (position higher if the abdomen is long or the hepatic flexure high).  We use the same port placement for an appendicectomy.  We have tried ALL other port palcements and believe that our approach has many benefits.  Try it for a few cases! 

If the tumour is stuck to the abdominal wall remove a cuff of internal oblique (it is much easier than in open surgery).

If a vessel bleeds apply local pressure – use the colon !  If it is brisk venous bleeding increase the abdominal pressure to 20mm Hg and apply steep headdown tilt.  Dont panic!

Start the omental dissection in the medial part of the transverse colon.
Use a medial or lateral approach as findings dictate – if there is no space/too much small bowel/very large tumour we would suggest that you start laterally.  In large tumours consider extracorporeal division of mesenteric vessels.

In a medial approach, grasp the ileocolic pedicle with a Johan forceps using your left hand and elevate ventrally.  Incise the peritoneum with the harmonic scalpel below the vascular bundle.  Mobilise the mesocolon from the retroperitoneum using a combination of the pneumoperitoneum and a posterior pressure from a closed harmonic scalpel.  Look out for the duodenum and elevate the mesocolon.  Return to the IC vascular pedicle.  Dissect out its origin with Harmonic and clip the vessel x3 with Haem-O-Lock clips.  Divide the vessel.
Identify the right colic vessels and clip these. 

In Crohns patients we would use an endo-stapler eg ATW45.  We use the same approach when the small bowel is distended or where there is minimal space.

Retract the terminal ileum in a medial, cranial direction to allow division of the peritoneum behind the caecum and ileum.  Continue with the dissection of the lateral attachments of the ascending colon.

Mobilise the hepatic flexure retracting the bowel medially and ventrally. 
Remove the specimen at the umbilicus through as small as hole as possible. ; 2 1/2 cm is usually sufficient. (divide the small bowel with a TLC75 and deliver the narrowest part of the tumour - end on through the umbilicus).  

In Crohn’s deliver the whole small bowel in small sections, returning each one before moving on to check for/treat strictures by stricturoplasties.  

If there is a previous incision eg for a crohns resection use it for the specimen extraction! This patient had an extended RHC having had a previous laparotomy for a perforated DU and a subsequent cholecystectomy.  Patients who have had a previous laparotomy tend to "fly" post RHC.

Our preference is a side to side stapled anastomosis.  It is widely patent and rarely leads to any "hold up" in the early postoperative period.  We never close the mesenteric defect.

Mop-up any blood from the paracoloic gutter using a small swab introduced into the abdominal cavity using a Rampley's forceps.  Avoid inserting a drain.  Remember to close the left sided 12mm port site.

We remove catheters after closing the umbilical incision.

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SPIRE Hospital, Bristol. 
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Contact: Claire Trenberth - 0117 9804051